Abdominal pain

Critical causes of abdominal

pain
Ruptured Ectopic Pregnancy
EPIDEMIOLOGI
• Occurs in females of childbearing age. No method of contraception
prevents ectopic pregnancy. Approximately 1 in every 100 pregnancies.
ETIOLOGY
• Risk factors include nonwhite race, older age, infertility treatment,
intrauterine contraceptive device placed within the past year, tubal
sterilization, and previous ectopic pregnancy.
PRESENTATION
• Severe, sharp constant pain localized to the affected side. More diffuse
abdominal pain with intraperitoneal hemorrhage. Signs of shock may be
present. Midline pain tends not to be ectopic pregnancy
PHYSICAL EXAMINATION
• Shock or evidence of peritonitis may be present. Lateralized
abdominal tenderness. Localized adnexal tenderness or cervical
motion tenderness increases the likelihood of ectopic pregnancy.
Vaginal bleeding does not have to be present
USEFUL TOOL(S)
• β-hCG testing is necessary in all females of childbearing age (10 to 55
years old); combined with ultrasonography, preferably transvaginal in
early pregnancy, usually is diagnostic. FAST examination is useful in
evaluating for free fluid in patients with shock or peritonitis.
Ruptured or Leaking abdominal Aneurism
EPIDEMIOLOGI
• Incidence increases with advancing age. More frequent in men. Risk factors
include Hypertension, DM, smoking, COPD, and CAD
ETIOLOGY
• Exact cause is undetermined. Contributing factors include atherosclerosis,
genetic predisposition, Hypertension, connective tissue disease, trauma,
and infection.
PRESENTATION
• Patient is often asymptomatic until rupture. Acute epigastric and back pain
is often associated with or followed by syncope or signs of shock. Pain may
radiate to back, groin, or testes.
PHYSICAL EXAMINATION
• Vital signs may be normal (in 70%) to severely abnormal. Palpation of
a pulsatile mass is usually possible in aneurysms 5 cm or greater. The
physical examination may be nonspecific. Bruits or inequality of
femoral pulses may be evident.
USEFUL TOOL(S)
• Abdominal plain films are abnormal in 80% of cases. Ultrasound can
define diameter and length but can be limited by obesity and bowel
gas. FAST examination can be helpful in evaluating for leak by looking
for free fluid. Spiral CT test of choice in stable patients.
Mesenteric ischemia
EPIDEMIOLOGI
Occurs most commonly in elders with CV disease, CHF, cardiac dysrhythmias, DM,
sepsis, and dehydration. Mortality is 70%. Mesenteric venous thrombosis is
associated with hypercoagulable states, hematologic inflammation, and trauma
ETIOLOGY
20% to 30% of lesions are nonocclusive. The causes of ischemia are multifactorial,
including transient hypotension in the presence of preexisting atherosclerotic
lesion. The arterial occlusive causes (65%) are secondary to emboli (75%) or acute
arterial thrombosis (25%).
PRESENTATION
Pain can be severe and colicky starting in the periumbilical region and then
becomes diffuse. Often associated with vomiting and diarrhea. Sometimes
postprandial ie, “mesenteric or abdominal angina.”
PHYSICAL EXAMINATION
Early examination results can be remarkably benign in the presence of severe
ischemia. Bowel sounds are often still present. Rectal examination is useful
because mild bleeding with positive guaiac stools can be present.

USEFUL TOOL(S)
Often a pronounced leukocytosis is present. Elevations of amylase and
creatine kinase levels are seen. Metabolic acidosis caused by lactic acidemia
is often seen with infarction. Plain radiographs are of limited benefit. CT,
MRI, and angiography are accurate to varying degrees.
Intestinal Obstruction
EPIDEMIOLOGI
Peaks in infancy and in the elderly. More common with history of
previous abdominal surgery.
PRESENTATION
Crampy diffuse abdominal pain associated with vomiting.
PHYSICAL EXAMINATION
Vital signs are usually normal unless dehydration or bowel
strangulation has occurred. Abdominal distention, hyperactive bowel
sounds, and diffuse tenderness. Local peritoneal signs indicate
strangulation

USEFUL TOOL(S)
Elevated WBC count suggests strangulation. Electrolytes may be
abnormal if associated with vomiting or prolonged symptoms.
Abdominal radiographs and CT are useful in diagnosis
Perforated Viscus
EPIDEMIOLOGI
Incidence increases with advancing age. History of peptic ulcer disease
or diverticular disease common
ETIOLOGY
More often a duodenal ulcer that erodes through the serosa. Colonic
diverticula, large bowel, and gallbladder perforations are rare. Spillage
of bowel contents causes peritonitis.
PRESENTATION
Acute onset of epigastric pain is common. Vomiting in 50%. Fever may
develop later. Shock may be present with bleeding or sepsis.
PHYSICAL EXAMINATION
Fever, usually of low grade, is common; worsens over time. Tachycardia
is common. Abdominal examination reveals diffuse guarding and
rebound. “Board- like” abdomen in later stages. Bowel sounds are
decreased.

USEFUL TOOL(S)
WBC count is usually elevated owing to peritonitis. Amylase may be
elevated; LFT results are variable. The upright radiographic view reveals
free air in 70% to 80% of cases with perforated ulcers.
Massive Gastrointestinal Bleeding
EPIDEMIOLOGI
More common in older adults ages 40 to 70.

PRESENTATION
Nausea and vomiting typically occur with upper GI bleeds with
hallmark coffee-ground or hematemesis; lower GI bleeds associated
with poorly localized discomfort and bright red blood per rectum
PHYSICAL EXAMINATION
• Non-focal abdominal tenderness; large bleeds may result in
tachycardia and hypotension with enough blood loss.
USEFUL TOOL(S)
Stool or gastric guaiac if there is a question of bleeding; massive bleeds
may require emergent consultation by gastroenterology or surgery to
intervene
Acute Pangreatitis
EPIDEMIOLOGI
Peak age is adulthood; rare in children and elders. Male preponderance.
Alcohol abuse and biliary tract disease are risk factors.
ETIOLOGY
Alcohol, gallstones, hyperlipidemia, hypercalcemia, or endoscopic retrograde
pancreatography causing pancreatic damage, saponification, and necrosis.
ARDS, sepsis, hemorrhage, and renal failure are secondary.
PRESENTATION
Acute onset of epigastric pain radiating to the mid-back. Nausea and
vomiting are common.
PHYSICAL EXAMINATION
Low-grade fever is common. Patient may be hypotensive or tachypneic.
Some epigastric tenderness is usually present. Because pancreas is
retroperitoneal organ, guarding or rebound not present unless condition is
severe. Flank ecchymosis or periumbilical ecchymosis may be seen if process
is hemorrhagic.

USEFUL TOOL(S)
Serum lipase is the test of choice. Ultrasound examination may show edema,
pseudocyst, or biliary tract disease. CT scan may show abscesses, necrosis,
hemorrhage, or pseudocysts. Ultrasound is recommended to assess for
gallstones while CT is recommended if severe acute pancreatitis is suspected.
Emergent Causes Of Abdominal Pain
Gastric, esophageal,or duodenal inflamation
PRESENTATION
Pain is epigastric, radiating or localized, associated with certain foods. Pain may be
burning.
PHYSICAL EXAMINATION
epigastric tenderness without rebound or guarding. Perforation or bleeding leads
to more severe clinical findings.

USEFUL TOOL(S)
Uncomplicated cases are treated with antacids or histamine H2 blockers before
invasive studies are contemplated. Gastroduodenoscopy is valuable in diagnosis
and biopsy. If perforation is suspected, an upright chest radiograph is obtained
early to rule out free air. CT may be beneficial
Acute Apendicitis
ETIOLOGY
Appendiceal lumen obstruction leads to swelling, ischemia, infection, and
perforation.
PHYSICAL EXAMINATION
Mean temperature 38° C (100.5° F). Higher temperature associated with
perforation. RLQ tenderness (90% to 95%) with rebound (40% to 70%) in majority
of cases. Rectal tenderness in 30%.

USEFUL TOOL(S)
Leukocyte count is nonspecific and may be normal or elevated. Urinalysis may show
sterile pyuria. CT is sensitive and specific. US may have use in those with normal
body habitus (non-obese), women, pregnancy, and children with RLQ pain
Biliary tract disease
EPIDEMIOLOGI
Peak age 35 to 60 years old; unlikely in patients younger than 20. Female-to-
male ratio of 3:1. Risk factors include multiparity, obesity, alcohol intake, and
use of birth control pills.
ETIOLOGY
Passage of gallstones causes biliary colic. Impaction of a stone in cystic duct
or common duct leads to cholecystitis or cholangitis.
PRESENTATION
Crampy RUQ pain radiates to right subscapular area. May have nausea or
postprandial pain. Longer duration of pain favors diagnosis of cholecystitis or
cholangitis.
PHYSICAL EXAMINATION
Temperature is normal in biliary colic, elevated in cholecystitis and
cholangitis. RUQ tenderness, rebound, and jaundice (less common)
may be present.
USEFUL TOOL(S)
WBC is count elevated in cholecystitis and cholangitis. Lipase and liver
function tests may help differentiate this from gastritis or ulcer disease.
US shows wall thickening, pericholecystic fluid, stones, or duct
dilatation.
Ureteral colic
EPIDEMIOLOGI
Average age for first episode is 30 to 40 years old, primarily in men. Prior
history or family history of stones is common.
PRESENTATION
Acute onset of flank pain radiating to groin. Nausea, vomiting, and pallor are
common. Patients are usually writhing in pain.
PHYSICAL EXAMINATION
Vital signs are usually normal. Tenderness on CVA percussion with benign
abdominal examination.
USEFUL TOOL(S)
Urinalysis usually shows hematuria. Noncontrast CT is sensitive and specific.
Diverticulitis
ETIOLOGY
Colonic diverticula may become infected or perforated or cause local colitis.
Obstruction, peritonitis, abscesses, fistulae result from infection or swelling.
PRESENTATION
Change in stool frequency or consistency commonly reported. LLQ pain is common.
Associated with fever, nausea and vomiting; rectal bleeding may be seen.
PHYSICAL EXAMINATION
Fever usually of low grade. LLQ pain without rebound is common. Stool may be
heme positive.
USEFUL TOOL(S)
Results on most tests usually normal. Plain radiographs not indicated. CT is
diagnostic, but diagnosis is often made clinically, without imaging.
Acute Gastroenteritis
EPIDEMIOLOGI
Seasonal. Most common misdiagnosis of appendicitis. May be seen in
multiple family members. History of travel or immunocompromise.
ETIOLOGY
Usually viral. Consider invasive bacterial or parasitic cause in prolonged
cases, in travelers, or immunocompromised patients.
PRESENTATION
Pain usually poorly localized, intermittent, crampy, and diffuse.
Diarrhea is key element in diagnosis; usually large volume, watery.
Nausea and vomiting usually begin before pain.
PHYSICAL EXAMINATION
Abdominal examination usually nonspecific without peritoneal signs.
Watery diarrhea or no stool noted on rectal examination. Fever is
usually present.
USEFUL TOOL(S)
Usually symptomatic care with antiemetics and volume repletion.
Heme-positive stools may be a clue to invasive pathogens. Key is not
using this as a “default” diagnosis and missing more serious disease.
Constipation and Obstipation
EPIDEMIOLOGI
More common in females, elders, the very young, and patients on narcotics.
ETIOLOGY
Idiopathic or hypokinesis secondary to disease states (low motility) or exogenous
sources (diet, medications).
PRESENTATION
Abdominal pain; change in bowel habits.
PHYSICAL EXAMINATION
Variable, nonspecific without peritoneal signs. Rectal examination may reveal hard
stool or impaction.
USEFUL TOOL(S)
Radiographs may show large amounts of stool.
Empirical Management
• There is no evidence to support withholding analgesics from patients with
acute abdominal pain to preserve the accuracy of subsequent abdominal
examinations. Ketorolac has been shown to cause increased bleeding times
in healthy volunteers and should be avoided in patients with
gastrointestinal bleeding or potential surgical candidates.
• The burning pain caused by gastric acid may be relieved by antacids.
Antiemetics can be helpful for nausea and vomiting. The 5-HT antagonists,
such as ondansetron, produce excellent results with minimal side-effects.
Other agents, such as promethazine, prochlorperazine, or droperidol, also
can be useful, but the mixed anticholinergic and antihistamine properties
of these medications can cause sedation and extrapyramidal side effects.
Extra-pyramidal side effects can be treated, if necessary, with
diphenhydramine, benztropine, or benzodiazepines.
• If intrabdominal infection is suspected, broad-spectrum antibiotic therapy
Disposition
• Before discharge of a patient with an undiagnosed cause of nonspecific
abdominal pain, several conditions should be met. The abdominal examination
findings should not indicate serious organ pathology or peritoneal irritation, and
the patient should have normal or near-normal vital signs. Pain and nausea
should be controlled, and the patient should be able to take fluids by mouth. If a
patient is to be discharged home without a specific diagnosis, clear instructions
should be given and include the fol- lowing information:
• • What to do for relief of symptoms or to maximize chances of resolution of the
condition (eg, avoiding exacerbating food or activities, how to take any
medications prescribed)
• • Under what circumstances, with whom, and how soon to seek follow-up
evaluation
• • Under what conditions to seek more urgent care or return to the ED
Key Concepts
• Certain patients with abdominal pain, including elder patients, women of
reproductive age, the immunocompromised, patients with cancer, and those who
have undergone prior surgery (especially bariatric surgery) are more likely to
harbor a serious diagnosis for their abdominal pain presentation and more often
require imaging than their otherwise healthy counterparts.
• Early bedside ultrasound is indicated for patients with signs of shock. Ultrasound
may identify aortic aneurysm or free intra-peritoneal blood, indicating the need
for rapid surgical intervention.
• The WBC count is non-diagnostic in the evaluation of patients with abdominal
pain, and neither elevation nor normal range results should be considered
confirmatory of a diagnostic impression.
• Ultrasound is superior to CT scanning for the diagnosis of pain originating in the
biliary tract or pelvis.
• Plain radiographs are rarely useful, and should only be obtained in the
rapid detection of free air or obstruction, when there is no intent to
proceed to CT scan if the radiograph is positive or negative.
• Pain medication does not impede diagnosis and should not be withheld
during diagnostic evaluation.
• Close to half of all patients with abdominal pain will not get a definitive
diagnosis in the ED. Select populations may be suitable for discharge with
appropriate close follow-up.
• First line antibiotics for serious intraperitoneal infections should be broad
spectrum, including anaerobic coverage, such as piperacillin/ tazobactam
3.375 g or ciprofloxacin 500 mg plus metronidazole 500 mg.
MATUR NUWUN